Complaint Investigation Report

R1's responsible party stated that the Medication Technician, Staff 1, only had the tackle box with her into the resident 1's room. Staff 1 did not have the medication cart with the laptop in order to check the medication. Staff 1 had to return to the medication room, bring the medications and showed the medications to the two responsible parties. This is when the medication error was discovered. Photographs were taken of the two medications about to be given to R1.

Based on the information gathered during the investigation and review of all documents obtained, the following allegations: 1)Facility mismanaged resident's medication.

2)Facility failed to provide competent staff to meet resident's needs.

Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are cited today as per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted along with appeal rights were provided and a copy of this report was left.